<html><head>
        <title>Formulir Data Kelahiran Penduduk</title>

        <link href="<?php echo base_url('assets/css/formkelahiran.css') ?>" rel="stylesheet" type="text/css" />  
        <link href="<?php echo base_url('assets/js/jquery-ui.css'); ?>" rel="stylesheet" type="text/css" />
        <script type="text/javascript" src="<?php echo base_url('assets/js/jquery-1.9.1.js'); ?>"></script>
        <script type="text/javascript" src="<?php echo base_url('assets/js/jquery-ui.js'); ?>"></script>              


        <script type="text/javascript">
            $(function() {
                $("#tgl_lahir").datepicker({changeMonth: true, changeYear: true});
            });
        </script>        
    </head>
    <body>
        <form action="<?php echo base_url('kelahiran/tambah'); ?>" method="post">
            <table width="761" border="0" align="center">
  <tr>
                    <td colspan="7" class="trheader">Formulir Data Kelahiran Penduduk</td>
                </tr>
                <tr>
                    <td>No. Surat Kelahiran</td>
                    <td colspan="3"><input type="text" name="no_form" id="no_form" class="textinput" placeholder=""/></td>
                    <td colspan="3">&nbsp;</td>
                </tr>
                <tr>
                    <td>Nomor Kartu Keluarga</td>
                    <td colspan="3"><input type="text" name="no_kk" id="no_kk" class="textinput" placeholder="3501062001053536"/></td>
                    <!--<td colspan="3"><input type="button" name="cari_kk" id="cari_kk" value="Cari Data KK" class="radiobutton-kiri"/></td>-->
                </tr>
                <tr>
                    <td colspan="7" class="jeda">Data Bayi</td>
                </tr>
                <tr>
                    <td width="181">Nama Bayi</td>
                  <td colspan="3"><input type="text" name="namabayi" id="namabayi" class="textinput" placeholder="Niken Larasati" /></td>
                    <td width="62">&nbsp;</td>
                  <td colspan="2">&nbsp;</td>
                </tr>
                <tr>
                    <td>Jenis Kelamin</td>
                    <td colspan="6"><select name="idjenis_kelamin" class="list">
                      <?php
                            if (isset($jenis_kelamin)) {
                                foreach ($jenis_kelamin->result() as $data_jenis_kelamin) {
                                    echo '<option class="radiobutton" value="' . $data_jenis_kelamin->idjenis_kelamin . '">' . $data_jenis_kelamin->jenis_kelamin . '</option>';
                                }
                            }
                            ?>
                    </select></td>
                </tr>
                <tr>
                  <td>&nbsp;</td>
                  <td colspan="3">&nbsp;&nbsp;Berat
                  <input type="text" name="brt_bayi" id="brt_bayi" class="textinputdua" placeholder="3,1" />
                  kg</td>
                  <td colspan="3">Panjang
                  <input type="text" name="pjg_bayi" id="pjg_bayi" class="textinputdua" placeholder="50" />
                  cm</td>
                </tr>
                <tr>
                    <td>Tempat Dilahirkan</td>
                    <td colspan="3">
                        <select name="tempat_dilahirkan" id="tempat_dilahirkan" class="list">
                        <option value="RS/RB">RS/RB</option>
                            <option value="Puskesmas">Puskesmas</option>
                            <option value="Polindes">Polindes</option>
                            <option value="Rumah">Rumah</option>
                            <option value="Lainnya">Lainnya</option>
                        </select></td>
                    <td>&nbsp;</td>
                    <td colspan="2">&nbsp;</td>
                </tr>
                <tr>
                    <td>Tempat Kelahiran</td>
                    <td colspan="3"><input type="text" name="tempat_kelahiran" id="tempat_kelahiran" class="textinput" placeholder="Pacitan" /></td>
                    <td>&nbsp;</td>
                    <td colspan="2">&nbsp;</td>
                </tr>
                <tr>
                    <td>Tanggal Lahir</td>
                    <td colspan="6"><input type="text" name="tgl_lahir" id="tgl_lahir" class="textinputtiga" placeholder="TANGGAL" />
                        &nbsp;&nbsp;Pukul
                        <input type="text" name="pukul" id="pukul" class="textinputdua" placeholder="12:34" />
                        WIB</td>
                </tr>
                <tr>
                    <td>Kelahiran ke- </td>
                    <td colspan="3"><input type="text" name="kelahiran_ke" id="kelahiran_ke" class="textinputdua" placeholder="2" /></td>
                    <td>&nbsp;</td>
                    <td colspan="2">&nbsp;</td>
                </tr>
                <tr>
                    <td>Jenis Kelahiran</td>
                    <td colspan="3"><select name="idjenis_kelahiran" class="list">
                            <?php
                            if (isset($jenis_kelahiran)) {
                                foreach ($jenis_kelahiran->result() as $data_jenis_kelahiran) {
                                    echo '<option class="radiobutton" value="' . $data_jenis_kelahiran->idjenis_kelahiran . '">' . $data_jenis_kelahiran->jenis_kelahiran . '</option>';
                                }
                            }
                            ?>
                        </select></td>
                    <td>&nbsp;</td>
                    <td colspan="2">&nbsp;</td>
                </tr>
                <tr>
                    <td>Penolong Kelahiran</td>
                    <td colspan="3"><select name="penolong" id="penolong" class="list">
                            <option value="dok">Dokter</option>
                            <option value="bid">Bidan / Perawat</option>
                            <option value="duk">Dukun</option>
                            <option value="lain">Lainnya</option>
                        </select></td>
                    <td>&nbsp;</td>
                    <td colspan="2">&nbsp;</td>
                </tr>
                <tr>
                    <td colspan="7" class="jeda">Data Ibu</td>
                </tr>
                <tr>
                    <td>NIK Ibu</td>
                    <td colspan="3"><input type="text" name="nik_ibu" id="nik_ibu" class="textinput" placeholder="3501064405670003"/></td>
                   <!-- <td colspan="3"><input type="submit" name="cari_ibu" id="cari_ibu" value="Cari Data Ibu" class="radiobutton-kiri"/></td>-->
                </tr>
                <tr>
                    <td colspan="7" class="jeda">Data Ayah</td>
                </tr>
                <tr>
                    <td>NIK Ayah</td>
                    <td colspan="3"><input type="text" name="nik_ayah" id="nik_ayah" class="textinput" placeholder="3501061201660002"/></td>
                    <!--<td colspan="3"><input type="submit" name="cari_ayah" id="cari_ayah" value="Cari Data Ayah" class="radiobutton-kiri"/></td>-->
                </tr>
                <td colspan="7" class="jeda">Data Pelapor</td>
                </tr>
                <tr>
                    <td>NIK Pelapor</td>
                    <td colspan="3"><input type="text" name="nik_pelapor" id="nik_pelapor" class="textinput" placeholder="3501061411910002"/></td>
                    <!--<td colspan="3"><input type="submit" name="cari_pelapor" id="cari_pelapor" value="Cari Data Pelapor" class="radiobutton-kiri"/></td>-->
                </tr>
                <tr>
                    <td>Hubungan Pelapor dengan bayi</td>
                    <td colspan="3"><input type="text" name="hub_pelapor" id="hub_pelapor" class="textinput" placeholder="Ayah" /></td>
                    <td>&nbsp;</td>
                    <td colspan="2">&nbsp;</td>
                </tr>
                <tr>
                    <td colspan="7" class="jeda">Data Saksi</td>
                </tr>
                <tr>
                    <td>NIK Saksi 1</td>
                    <td colspan="3"><input type="text" name="nik_saksi_satu" id="nik_saksi_satu" class="textinput" placeholder="3501061411910002"/></td>
                    <!--<td colspan="3"><input type="submit" name="cari_saksi" id="cari_saksi" value="Cari Data Saksi" class="radiobutton-kiri"/></td>-->
                </tr>
                <tr>
                    <td>NIK Saksi 2</td>
                    <td colspan="3"><input type="text" name="nik_saksi_dua" id="nik_saksi_dua" class="textinput" placeholder="3501061411910002"/></td>
                    <!--<td colspan="3"><input type="submit" name="cari_saksi" id="cari_saksi" value="Cari Data Saksi" class="radiobutton-kiri"/></td>-->
                </tr>
                <tr>
                  <td colspan="3">&nbsp;</td>
                  <td width="213">&nbsp;</td>
                  <td>&nbsp;</td>
                  <td width="89">&nbsp;</td>
                  <td width="160">&nbsp;</td>
                </tr>
                <tr>
                    <td colspan="3">&nbsp;</td>
                    <td><input type="submit" name="tambah" id="tambah" value="Tambah" class="btn btn-large"/></td>
                    <td>&nbsp;</td>
                    <td>&nbsp;</td>
                    <td>&nbsp;</td>
              </tr>
            </table>

    </form>
    </body>
</html>
